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Clinical conundrum

Clinical conundrum. 2010 Midwest Pediatric Hospital Medicine Conference June 12, 2010 Matthew Johnson, MD. Chief complaint. 6 month old hispanic male with fever for 12 days and intermittent use of right arm. HPI. Fever as high as 105 daily x12 days, average 103, no pattern

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Clinical conundrum

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  1. Clinical conundrum 2010 Midwest Pediatric Hospital Medicine Conference June 12, 2010 Matthew Johnson, MD

  2. Chief complaint 6 month old hispanic male with fever for 12 days and intermittent use of right arm

  3. HPI • Fever as high as 105 daily x12 days, average 103, no pattern • Defervesces briefly with acetaminophen/ibuprofen • Fussy, not wanting to be held • Intermittently refusing to use right arm • Pain with movement of neck

  4. HPI – cont’d • Not rolling over anymore or scooting/crawling • Some intermittent rash to lower extremities • Seen in UCC/ED/PCP x 4, CXR and labwork unremarkable • Right arm/shoulder films negative • Admitted from ED following LP

  5. Past Medical History • Born full term by SVD • Birth weight 9#1oz • Mother positive for GBBS, treated with antibiotics • No subsequent hospitalizations, surgeries, or chronic illnesses

  6. Medications • Acetaminophen 80mg prn fever • Ibuprofen 80mg prn fever

  7. Allergies • No allergies or adverse reactions to any medications or foods

  8. Immunizations • Received 2 month immunizations, but not 4 or 6 month immunizations

  9. Family History • Non-contributory

  10. Social History • Patient lives with parents, 2 sisters, and 2 brothers • Exposed to dogs • No day care • Mom from Puerto Rico, Dad from Nicaragua • Both parents in US since childhood • Patient has never left Kansas City • No recent foreign visitors

  11. Review of Systems • HEENT – intermittent eye redness, no drainage, no congestion, no tongue or lip changes • Pulmonary – no cough, no wheezing • CV – negative • GI – decreased po intake, no vomiting or diarrhea, some gas • GU – normal uop • Bone/Skin/Joint – intermittent rash to lower extremities, no hand or feet swelling • Neurologic – irritable, cries when held, ? Loss of milestones

  12. Physical Exam • VS: T 37.3 HR 149 R 45 BP 124/81 • WT 8.7 KG • GEN: awake, alert and NAD. Not ill or toxic appearing. • HEAD/NECK: AFSF. NCAT. Supple. Passive ROM is normal. Neck is nontender. • EYES: PERRL. EOMI. No eye discharge or erythema. • ENT: TMs and pharynx are clear. No pharyngeal asymmetry. MMM. No nasal flaring or discharge. • CHEST: clear and without retractions. • CV: RRR and no murmur. Brisk CR.

  13. Physical Exam • ABD: soft, NT, ND. No HSM or masses appreciated. • GU: normal male with bilaterally descended testicles. • LYMPH: no adenopathy. • EXT: warm, pink and well perfused. No point tenderness of the spinal processes, extremities, clavicles, or joints. No joint edema or erythema.

  14. Physical Exam • NEURO: Normal mental status for age. Normal muscle tone and strength for age. • Ability to sit is appropriate for age. Able to bear weight with his legs with assistance. Spontaneous movement of all extremities. • SKIN: mild, faint erythematous macular rash on the anterior thighs with R greater than left. No petechiae or vesicular lesions.

  15. Differential Diagnosis

  16. Labs/Studies CBC BMP Urinalysis Liver Function Tests Inflammatory Markers Body Fluid Analysis Pathology Microbiology CXR CT Scan MRI 2-D Echo Other Studies Other Imaging Clinical Course

  17. CBC 9.2 1,189 20.3 27.2 Neut 52, Lymph 38, Mono 8 MCV 77

  18. BMP 133 102 5 88 22 0.5 4.8 Ca 9.2 (8.8-10.5)

  19. Sp. G. > 1.030 pH 7.5 Bloodnegative Ketonesnegative Glunegative Prot 1+ LE negative Urobil negative Bilinegative Urine Analysis Micro – no RBC, no WBC

  20. AST 48 (20-50) ALT 63 (20-50) Alk. Phos102 (40-125) Bilirubin0.2 (0-1.1) Total protein 6.6 (6.2-8.3) Albumin 3.6 (3.6-4.6) Liver Function Tests

  21. CRP – 1.3 ESR – 83 Inflammatory Markers

  22. Body Fluid Analysis CSF RBC 534 WBC 27 (6 seg, 10 lymph, 84 mono) Glucose 46 Protein 114 Gram stain – no organisms, moderate WBC

  23. Pathology • A. Spinal cord, dura and soft epidural tissue, T2 level, biopsy: • MACROPHAGE/HISTIOCYTIC AND NEUTROPHILIC INFILTRATES CONSISTENT WITH INFECTION/ EPIDURAL ABSCESS AS DESCRIBED. • B. Spinal cord, dura and soft epidural tissue, T2 level, biopsy: • MACROPHAGE/HISTIOCYTIC AND NEUTROPHILIC INFILTRATES CONSISTENT WITH INFECTION/ EPIDURAL ABSCESS AS DESCRIBED

  24. Microbiology • Blood culture negative • Urine culture negative • CSF culture negative • CSF enterovirus PCR negative • EBV titers negative • CMV titers negative • Viral Respiratory PCR negative • PPD negative

  25. IMPRESSION: Peribronchial thickening consistent with bronchiolitis or reactive airways disease. No evidence of focal pneumonia. CXR

  26. CT Scan

  27. CT Scan

  28. CT Scan Permeative and destructive appearance involving the T2 vertebral body with associated paraspinal phlegmon and intraspinal phlegmon which is producing effacement of the spinal cord. There are areas within the intraspinal phlegmon which are suggestive of abscess formation. An MRI with contrast and diffusion weighted imaging is recommended for further evaluation.

  29. MRI

  30. MRI

  31. MRI 1. Imaging findings consistent with vertebral osteomyelitis centered at the T2 vertebral level but with abnormal marrow signal and enhancement extending from T2-T4. 2. Complicating epidural abscess formation with displacement of the spinal cord left of midline. The spinal canal is compromised by approximately 50% at the T2 vertebral level. No large paraspinous soft tissue abnormality identified. 3. While findings may relate to bacterial osteomyelitis, granulomatous disease/tuberculosis should also be in the differential considerations.

  32. 2-D Echocardiogram 1. Possible mildly ectatic left main coronary artery. 2. Normal-appearing right coronary artery. 3. Normal LV dimensions and systolic function. 4. No mitral or aortic valve regurgitation. 5. No pericardial effusion. 6. Recommend sedated study for better evaluation of coronary arteries if Kawasaki's is a clinical concern. Sedated echo – normal coronary arteries

  33. Other Imaging Right shoulder film – 2 view no fracture or dislocation Cervical spine film – 2 view normal C-spine

  34. Other Studies • LDH – 713 • Uric Acid – 2.0 • Culture from spinal abscess – methicillin sensitive Staph aureus

  35. Diagnosis Thoracic (T2) osteomyelitis, discitis, and spinal abscess secondary to MSSA

  36. Clinical Course • Started on ceftriaxone at meningitic dosespending CSF cultures • Seemed to improve • Infectious diseases consulted, concern for Kawasaki’s • Treated with IVIG and started on aspirin • Following MRI findings, vancomycin was added • Neurosurgery consulted and underwent laminectomy and spinal abscess drainage • Tolerated very well, cultures grew MSSA • Treated with IV antibiotics for 10 days, oral linezolid for 14 days, and oral cephalexin to complete 6 week course

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